Shin-Ping Tu, MD, MPH ; Maria Fernandez, PhD, Vicki Young, PhD on behalf of the CPCRN FQHC Workgroup Investigators

1. The Cancer Prevention and Control Research Network: Federally Qualified Health Centers Workgroup Shin-Ping Tu, MD, MPH ; Maria Fernandez, PhD, Vicki Young, PhD on behalf of the CPCRN FQHC Workgroup Investigators CDC September 24, 2013 This presentation was supported by Cooperative Agreement Numbers U48-DP001909, U48-DP001946, U48-DP001924, U48-DP001934, U48-DP001938(03), U48-DP001944, U48-DP001936, U48-DP001949-02, U48–DP001911, & U48-DP001903 from the Centers for Disease Control and Prevention. The findings and conclusions in this presentation are those of the author(s) and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

2. CPCRN CHC Survey Primary Care Associations National Association of Community Health Centers (NACHC) Community Health Centers (CHCs) • Align with CHCs’ • missions Guided by real world health policy & health care delivery landscapes Health Care Reform Meaningful Use of EHR Patient-Centered Medical Home

3. CPCRN CHC Survey Frameworks • PCMH & Practice Change and Development Model • Consolidated Framework for Implementation Research (CFIR) Sections A - Clinician Staff Questionnaire (Transformed’s NDP) 23 item Practice Adaptive Reserve (PAR) Scale B - Primary CRC screening modality recommended at clinic C - 4 Community Guide EBIs to increase CRC screening: Provider reminders, Patient reminders One-on-one education, Provider assessment and feedback EBI specific CFIR items D - 8 CRC screening best practices - NCQA PCMH standards How often performed best practices in past month E - Age, gender, race and ethnicity, languages spoken, number of hours/wk and years worked at clinic

4. CPCRN CHC Survey Convenience sample of CHC clinics from 7 states Completed May 30, 2013 327 providers, nurses, MAs, QI/operations staff Missing Frequencies =11

5. Clinic Characteristics Survey - Content • Patients served • Uninsured, below poverty level, LEP, race/ethnicity • Number of encounters • Staffing - FTEs & shortages • EHR • Ease to generate information & accuracy of data • PCMH best practices • 8 Community Guide EBAs • Provider reminder implementation • Pressures, incentives, alignment with QI • Feedback on CRC screening • CDC funding of CRC screening program • CRC screening reporting to outside organization • Scores well – additional income/reimbursements/other rewards

6. CHC Clinic Characteristics Respondents - CEO (6); CMO/Med Director (8); CNO/Nursing Director (3); COO/Clinic Operations Director (3); QI Director/Manager (11); Others (19)

7. CHC Staffing Shortages

8. Practice Change and Development Model Miller et al. Primary Care Practice Development: A Relationship-Centered Approach. Ann Fam Med 2010;8(Suppl 1):s68-s79.

9. Robust Practice Core consistent performance & delivery of reliable primary care Miller et al. Primary Care Practice Development: A Relationship-Centered Approach. Ann Fam Med 2010;8(Suppl 1):s68-s79.

10. Practice Adaptive Reserve enhances resilience & facilitates adaptation and development Miller et al. Primary Care Practice Development: A Relationship-Centered Approach. Ann Fam Med 2010;8(Suppl 1):s68-s79.

11. Practice Adaptive Reserve Scores by State • National Demonstration Project - Highly-motivated practices w/ significant capability for change • Mean baseline PAR score 0.69 (s.d. 0.35) • Post intervention PAR score increased to 0.74 Scores are scaled so as to range from 0.00 to 1.00; 1.00 = perfect score of agreement

12. PCMH CRC Screening Best Practices (%)

13. Adjusted Regression Analysis PCMH Best Practices and PAR PCMH Best Practices Mean Composite Score (0-32) Adjusted for state, age, job type, years worked at the clinic, hours worked each week • Differences b/t PCMH BP Mean Composite Scores all statistically significant: • 0.08 - 1.00 vs. 0.06 - <0.80 (p = 0.0013) • 0.08 - 1.00 vs. 0.00 - <0.60 (p = <0.0001) • 0.06 - <0.80 vs. 0.00 - <0.60 (p = 0.0155)

14. Adjusted Logistic Regression Frequency of PCMH Best Practices and PAR Scores PCMH Best Practices Dichotomized Score (6-8 vs. 0-5) Respondent reported performing PCMH best practices “usually” or “always” Adjusted for state, age, job type, years worked at the clinic, hours worked each week

15. Levels of Community Guide EBI Implementation

16. Implementation Levels of CRC Screening EBIs Missing Frequencies: 20

17. General Predictors of Implementation of Provider Reminders • *Odds ratio over 1 means associated with higher levels of provider reminder implementation • Adjusted for age, education, and state. • Number of respondents =296; Number of clinics: 75/62 Unit of Analysis: multilevel PAR (Scaled 0-5) Odds Ratio=2.33; P value=0.0238

18. EBI-Specific Predictors of Implementation of Provider Reminders • *Odds ratio over 1 means associated with higher levels of provider reminder implementation • Adjusted for age, education, and state. • Number of respondents =296; Number of clinics: 75/62 Unit of Analysis: multilevel

19. Electronic Health Record Adoption N=50

20. Electronic Health Record Functionality

21. Electronic Health Record Accuracy *Primary source for reports or patient care decision **Need a secondary audit or cross check with additional documentation ***Would not use for reports or patient care decision

22. Summary In 3 months since survey concluded, we have identified: • Positive associations of PAR with CRC screening BPs • Room to go to fully and systematically implement the CG EBIs at participating clinics • Associations of PAR and certain CFIR constructs with implementation of Provider Reminders • Limitations of EHR CRC screening data

23. Summary In 3 months since survey concluded, we have identified: • Positive associations of PAR with CRC screening BPs • Room to go to fully and systematically implement the CG EBIs at participating clinics • Associations of PAR and certain CFIR constructs with implementation of Provider Reminders • Limitations of EHR CRC screening data

24. FQHC Survey Subgroup: Manuscripts

25. Acknowledgements Special thanks to: CPCRN FQHC Workgroup Team Alan Kuniyuki MS, Letoynia Coombs PhD Allison Cole, MD, MPH Jim Hotz MD Kathleen Clark CHC contacts Survey respondents Contact Information: shinping@uw.edu This work was also supported by National Cancer Institute grants R21 CA 136460 and R01 CA124397